1. American Public Health Association
THE URBAN INSTITUTE
Developmental Content of Primary Care for Newly Insured Young Children in Los Angeles
Embry Howell, Ph.D., Urban Institute
Moira Inkelas, Ph.D., UCLA
Patricia Barreto, M.D., UCLA
Louise Palmer, M.A., Urban Institute
Poster Presentation:
American Public Health Association
November 6, 2007

2. Background: Purpose of Los Angeles Healthy Kids
Enhance outreach and enrollment for Medi-Cal, Healthy Families, and Healthy Kids
Offer new insurance product, “Healthy Kids,” to children ineligible for Medi-Cal and Healthy Families
Improve health service access and use

3. Evaluation of Los Angeles Healthy Kids
Joint project of the Urban Institute, UCLA, USC, and Mathematica Policy Research
Sponsored by First 5 Los Angeles
Evaluation began in 2004
Multiple components
Process analysis (focus groups/interviews)
Process monitoring
Client survey and analysis

4. Evaluation Questions
What is the level and quality of developmental care provided to Healthy Kids enrollees?
Does quality of preventive care increase after young children obtain health insurance?
Does quality of care increase with time in the program?

5. Participant Survey Wave One: April – December, 2005
Wave Two: May, 2005 – January, 2006
Sample Size (Response Rate):
Initial Sample: 1262 children ages 1-5
Interviewed in Wave One: 1087 (86%)
Interviewed in both waves: 975 (77%)
Most (88%) interviews in Spanish
Descriptive Wave One results presented in October 2006 report, available on UI website (

6. Survey Content
Items from other child health insurance expansion evaluation surveys
Items on developmental services taken from the Promoting Healthy Development Survey (Bethell, et al.) as used in the National Survey of Early Childhood Health

7. Components of Developmental Services
Receiving developmental assessment
Developmental surveillance (asking about parent concerns) to identify possible developmental problems
Receiving health education/counseling on important topics (“Anticipatory Guidance”)
Referral to specialty care and community-based resources for possible developmental problems

8. Developmental Content: Assessment
During the past 6 months, did child’s providers tell you they were doing a developmental assessment?
During the time period, did the providers have your child roll over, pick up blocks, etc.?
Did the provider ask if your child did those things?

9. Developmental Content: Eliciting Parent Concerns
Are you concerned a lot, a little, or not at all about any of the following:
How your child talks and makes speech sounds?
How he/she understands what you say?
How he/she uses his/her hands and fingers to do things?
How he/she uses his/her arms and legs?
How he/she behaves?
How he/she gets along with others?
How he/she is learning to do things for himself/herself?
Your child’s feelings and moods?
Whether your child can do what other children his/her age can do?

10. Developmental Content: Anticipatory Guidance
During the past 6 months did your providers talk with you about:
Helping kids grow and learn
Behaviors
Nutrition
Guidance and Discipline
Toilet training
Making house safe
Reading with child
Child care
WIC

11. Description of Study Cohorts: Characteristics at Baseline1 2 3 4 5
Non-citizen
Latino
Asian
Other
Citizen
Age
Race/ Ethnicity
Citizenship

12. Description of Study Cohorts: Characteristics at Baseline
0-1
2-3 4+
Parent/ spouse works full time
Parent/ spouse works part time
Neither works
<100% of poverty
>100% of poverty
Parent’s Length of Time in LA County (years)
Poverty Level
Parents’ Employment

13. Rates of Developmental Concerns, and Parent-Provider Discussions of Concerns
Ages 1-3
Age 4
Age 5
Provider Asked About Concerns
If Concerned, Provider Gave Info. About Concern
If No Info, Wished Provider Had Given Info.
Developmental Concerns

14. Most Parent Developmental Concerns are in Emotions, Behavior, Speech

15. Regression-Adjusted % Parents w/ Dev. Concerns
Rates of Developmental Concerns: Similar Before and After Coverage, and Between First and Second Year of Coverage
One Year Later
Regression-Adjusted % Parents w/ Dev. Concerns
WAVE ONE
WAVE TWO

16. With Developmental Assessment in Past 6 Months
Rates of Developmental Assessment: Vary by Child’s Age and Type of Usual Source of Care
Ages 1-3
Age 4
Age 5
Clinic
Other
With Developmental Assessment in Past 6 Months
Usual Source of Care

17. Regression-Adjusted % w/Dev. Assessment
Rates of Having Developmental Assessment: Increase with Coverage, No Difference Between First and Second Year of Coverage
One Year Later
Regression-Adjusted % w/Dev. Assessment
WAVE ONE
WAVE TWO
** Wave One Established greater than Wave One New (p<.05)

18. Rates of Anticipatory Guidance: Greater Coverage of Traditional than of Developmental Topics

19. Regression-Adjusted % w/guidance on 5+ topics
Rates of Receiving Anticipatory Guidance on 5+ Key Topics: No Differences with Coverage, and Between First and Second Years of Coverage
Regression-Adjusted % w/guidance on 5+ topics
WAVE ONE
WAVE TWO

20. Conclusions
Many parents have concerns about their young child’s development
Providers often do not ask about or address parent concerns, particularly for issues that involve:
Parent-provider relationships, (i.e. less “traditional” pediatric topics such as behavior, emotions and communication)
Referral resources
Intensive/time consuming interventions

21. Conclusions
Introducing new insurance coverage does not necessarily improve content of preventive/developmental services
More needs to be done to improve the quality of early childhood preventive care, which is the majority of care for young children
Improvements require:
Provider training
Greater cultural competency
Systems of care that support early identification
Greater capacity in early childhood specialized services (e.g., mental health)